Scott & White Care PlansERS Member Guide Plan Year 2021

Got a question?..........................................................................................................1

Get to know your ID card .....................................................................................2

Explore your member portal .............................................................................3

Download the MyBSWHealth App ..................................................................4

Experience Virtual Care........................................................................................4

Eligibility map..............................................................................................................5

Find a provider............................................................................................................5

Access pharmacy services.................................................................................6

Know your care options ... ....................................................................................7

Better health starts with you.............................................................................9

Naturally Slim ............................................................................................................10

Expecting the Best®..............................................................................................10

Get details on your claims .................................................................................11

Stay better, longer .................................................................................................13

Tools and resources ..............................................................................................14

Table of Contents

SWCP_GR_ERS_MemberGuide_PY2021

HMO products are offered through Scott and White Health Plan and Scott & White Care Plans. Insured PPO and EPO products are offered through Insurance Company of Scott and White. All are Texas registered insurance companies. Scott & White Care Plans and Insurance Company of Scott and White are wholly owned subsidiaries of Scott and White Health Plan.

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Got a question? Our highly trained Customer Advocates can help you with things like finding a provider and answering questions about your benefits or claims. Whatever your question or concern may be, our Customer Advocates will work with you to resolve it as quickly as possible—in most cases, before you hang up the phone.

Contact us through the member portalLog in at ers.swhp.org to send a secure email and receive a secure response.

Contact us by phone (800) 321-79477 a.m. – 7 p.m. CT Monday – Friday

Nurse Advice LineNurses are available 24/7 to talk through your symptoms and help you make decisions on next steps, whether that’s an appointment or an at-home remedy. The Nurse Advice Line phone number is on the back of your member ID card.

Additional Resources

Welcome to Scott & White Care Plans!Welcome to Scott & White Care Plans (SWCP), a wholly owned subsidiary of Scott and White Health Plan, and part of the Baylor Scott & White family of companies. We are proud to partner with ERS to offer healthcare coverage to those eligible under the Texas Employees Group Benefits Program (GBP), the largest group enrolled in SWCP. Currently, SWCP covers more than 18,000 GBP participants and their dependents.

If you have questions or need more information, please contact the following: For questions about your healthcare benefits, call SWHP toll-free at (800) 321-7947 (TTY: 711) and speak to a Customer Service Advocate For questions about enrollment and premiums, contact your benefits coordinator Employees of Health and Human Services (HHS) agency should contact the HHS Employee Service Center at (888) 894-4747 Retirees should call ERS Customer Service toll-free at (877) 275-4377

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The ID card above is a sample. The exact location of certain elements may vary on your card.

Get to know your member ID card

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2

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45

6

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Group name

Group ID number

Network name

Benefit effective date

Member name

Member ID number

Copays/coinsurance

Deductible

Pharmacy/prescription drug info9

Customer service phone number

24/7 Nurse Line

Information for providers

Claims mailing address

A

B

C

D

You can request a replacement ID card through the member portal oraccess an electronic card at any time through the MyBSWHealth app.

billing, find a provider at swhp.org

Self-service portal: ers.swhp.orgSWHP24/7 Nurse Line 1-000-000-0000

(TTY: 711)

00/00/0000

1 2

7

4

8 3

TDI

SUBSCRIBER John Sample

DOB: 00/00/0000

DEPENDENTS

Jane SampleJack SampleJill SampleJames SampleJulie SampleJoe SampleJackie Sample

MEMBER ID 00000000000

00000000000000000000000000000000000000000000000000000000000000000000000000000

IN-NETWORK PLAN BENEFITSAdult PCP/Spec: 00%

Pediatric PCP/Spec: 00% Emergency Room: 00%* Coinsurance:

N/A Deductible: I/$0000 F/$0000 Rx: 00%*Deductible:

I/$500, F/$1000PHARMACISTS ONLYOptumRx® Help Desk: 855-205-9182

BIN: 610011

PCN: IRX GRP:

Group: Group #: 000000Network:

*Deductible may apply.

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www.ers.texas.gov

ERS

SWPBSWCP

FOR PROVIDERSElectronic Claims:Availity: 94999

Paper Claims:Scott and White Health PlanPO Box 211342Eagan, MN 55121

Prior Authorization: Visit the provider portal Fax: 800-626-3042 Phone: 866-384-3488

Provider Portal:

Card Issue Date: 08/01/2020

FOR MEMBER S

not guarantee coverage or payment for the service or procedure reviewed.

Important Information:• In a medical emergency, call 9-1-1 or go to the nearest

emergency facility. • Customer Service: 844-633-5325 (TTY/TDD: 7-1-1)• Telehealth: Download the MyBSWHealth App• 24/7 Nurse Line: 877-505-7947• Self-Service Portal: my.bswhealth.com• To avoid out-of-network costs and provider balance

CUSTOMER SERVICE: 844-633-5325 ers.swhp.org

DC

AB

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Explore your member portalThere’s a wealth of information, resources, and functionality available 24/7 in our member portal, accessible from your computer or mobile device. You’ll find a link to the portal on our website: ers.swhp.org.

Download and/or print:

ID cards

Benefit Plan Documents

Claims summaries and Explanations of Benefits

Prescription medication history

Drug formulary

Pending, approved and denied authorizations Plus you can:

Find a provider

Make an appointment with a BSWH doctor

Complete a health assessment

Access virtual care options (eVisit and Video Visit)

Track your deductible and out-of-pocket maximum

Message your BSWH doctor

Refill a prescription at BSWH pharmacies

Verify eligibility

View/update demographic information

Learn about, and register for, the Expecting the Best® Maternity Program

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Download the MyBSWHealth appVirtually all of the information in the member portal is available on your phone through the MyBSWHealth app. For example, you can view a digital copy of your ID card, see plan details, and track your deductible and out-of-pocket maximum for yourself and your dependents. Use the same user name and password you set up for the member portal to log in to the app. To learn more, visit our website: ers.swhp.org

Be sure to link your account in the app:

Experience virtual care $0 copay

1. Tap the gear icon (top right corner of app welcome screen)2. Tap “Manage Linked Accounts”3. Tap “Link Account” 4. Enter member information

Conduct an eVisit for common medical conditions and get care fast

Click the eVisit icon under "URGENT CARE OPTIONS" Complete an online questionnare about your symptoms; it takes only 5-10 minutes You will get a response from a Baylor Scott & White Health provider within one hour Prescriptions (if needed) will be sent immediately to your preferred pharmacy

Schedule a same-day Video Visit with a provider, face-to-face

Click the video visit icon under “URGENT CARE OPTIONS” to schedule your appointment Talk with a Baylor Scott & White Health provider live about your symptoms Visits are quick: just 10-15 minutes Prescriptions (if needed) will be sent immediately to your preferred pharmacy

MyBSWHealth 8 a.m. - 8 p.m. CT, 7 days a week Receive care from the comfort of your home, or anywhere in Texas, at no cost to you.

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Find a Provider

Need more help? Call the Baylor Scott & White Quality Alliance Health Access Line:

(844) 279-7589

Our provider search tool at ers.swhp.org allows you to:

• Search by name, specialty and/or ZIP code

• Add filters for gender, board certification, accepting new patients and more

• See practice locations, contact information and maps

• Get details, including network participation and hospital affiliations

• Customize your own profile

Go to ers.swhp.org and scroll down the page to “Find a Provider” and you will be on your way.

Gillespie Blanco

Kendall

McCulloch

Mason

San SabaLampasas

Hays

Comal

Guadalupe

Gonzales

Caldwell

Bastrop

Lee

BurnetLlano

Coryell

BrownComanche

Hamilton

ErathHood

Parker Tarrant Dallas

Mills

Eastland EllisJohnson

BosqueHill

McLennan

Bell

Falls

Limestone

Navarro

Freestone

Robertson

Brazos

Madison

Walker

Grimes

Milam

Burleson

Washington

Colorado

Waller

Montgomery

Harris

Trinity

Houston

Travis

Denton Collin

Rockwall

Wharton

Fort Bend

Anderson

HendersonCallahan

Coleman

San Jacinto

Somervell

If you live or work in one of the blue counties, you will be eligible toparticipate in theGBP administered by SWCP for Plan Year 2021.

Plan Year 2021 Service Area

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S

Leon

Williamson

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Access pharmacy servicesSWCP members may access more than 68,000 pharmacies nationwide, including most national chains and a large selection of local pharmacies.

To find your nearest pharmacy, click here:

We also offer 90-day prescription refills for select medications at Baylor Scott & White Health pharmacies.

Get the convenience of home delivery with mail order service. Call our mail order pharmacy and we will walk you through the transfer process.

Call toll-free at (855) 388-3090 Monday through Friday, from 7 a.m. to 7 p.m. CT, and on Saturday, from 9 a.m. to 1 p.m. CT.

If you need detailed pharmacy claim information, pharmacy deductible information, explanation of benefits, or drug information and pricing, visit ers.swhp.org or call Customer Service at (800) 321-7947.

To view a formulary (a list of covered drugs), click here:

PHARMACY SEARCH

FORMULARIES

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Visit your Primary Care Physician when you’re sick or have a minor injury1

Your doctor knows your health history and underlying conditions. For routine illnesses and less significant injuries, many doctors’ offices are open on weekends and some evenings. This can be a good alternative to more costly urgent care or emergency care centers. Although a Primary Care Physician is not required, we encourage you to establish a relationship with a doctor.

If your doctor’s office is closed, consider an Urgent Care center2

Urgent Care centers typically have extended and weekend hours. Although costs are higher than primary care, urgent care copays are lower than those for emergency care.

Know your care optionsHow do you decide when a health-related issue is an emergency? Understanding your healthcare options can save your life... and your money.

Or opt for Virtual Care — or our Nurse Advice Line See page 4 for information on Virtual Care. Nurses are available to our members 24 hours a day, 365 days a year. Our nurses provide information about taking care of yourself at home or they can help you decide if an appointment, an urgent care visit, or an emergency room visit is best for your symptoms. To locate your appropriate Nurse Advice Line phone number, please look on the back of your member card or log in to the Member Portal.

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If you need to speak to us, contact us in the way that works for you. In addition to the Member Portal, customer support is available by phone at (800) 321-7947.

Scott & White Care Plans pays out-of-network emergency services according to Usual and Customary rates (industry standard), and members can be balance-billed for expenses beyond what insurance will pay. Your coverage documents contain additional information about emergency treatment and definitions of the terms, including a definition of emergency care. The coverage documents also contain information related to state-mandated consumer protections for facility-based provider charges.

To save on out-of-pocket costs, visit in-network emergency care facilities when possible. You can find in-network emergency care facilities by using the provider search tool at ers.swhp.org.

Remember: Out-of-network emergency care costs more

Emergency Rooms are best for treating severe and life-threatening conditions and they’re always open.3

The wider range of services offered through emergency rooms, and the hospitals they are connected to, makes emergency care a more expensive option, but sometimes the best option for you.

It’s important to understand your options, and to use your best judgment when deciding which option is right for you.

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Assessment for Members Assessment for Non-Members

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Use Corp ID 1011

WELL-BEING ASSESSMENTThe Well-Being Assessment is a simple, digital health survey that helps you take steps toward a more vibrant and healthier life. The Well-Being Assessment asks questions about your life and delivers customized action steps from our Lifestyle Management Program. Modules are self-paced, available online, and convenient for promoting physical and mental health — all things to help you feel your best.

Digital Health Coaching – 6-week coaching modules with action plans, important articles, online seminars and video content on topics that include:

• Live Tobacco Free • Healthy Weight

Progress Tracker – The digital platform has a dashboard to help you keep track of important health information like A1C, weight/BMI, cholesterol, blood pressure and physical activity. These biometric measurements can be charted over time to monitor your long-term health.

Fitness Tracker Integration – Synchronize your personal fitness tracker with the wellness platform to monitor your physical activity progress on the dashboard.

Digital Health Library – Access to articles, videos, recipes and other content to support a healthier life. You can search for condition-specific information or explore highlighted topics.

Challenges – Sometimes you need extra motivation to go the extra mile. You can participate in step challenges, hydration and even relaxation challenges.

Online Community – Access to online community forums where you can give and receive support for goals as well as get feedback from health coaches in the community.

• Healthier Diet • Active Living

Elevate your well-being with Scott & White Care Plans’ comprehensive suite of digital resources. Log in to your member portal to get started.

• Less Stress

Better health starts with you

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Expecting the Best® Maternity ProgramWe are pleased to offer a maternity program for pregnant Scott & White Care Plans members. This initiative is focused on helping expectant mothers enjoy a healthy pregnancy.

Once enrolled, participants can benefit from diverse program features for the duration of their pregnancy and one year postpartum.Participants receive helpful educational materials across distinct categories, including proper nutrition, early identification of pregnancy risk factors and available resources for any complications.

Sign up by calling the customer service number on the back of your ID card or send an email to: HPMaternityCaseManagement@BSWHealth.org.

Ever wonder how some people can eat all their favorite foods and not gain weight? Naturally Slim is an online program that will teach you how. And here’s a hint: it doesn’t include starving, counting calories or spending hours prepping ‘approved’ foods. SWCP is giving you the chance to learn how to eat the foods you love while reducing your risk of developing serious conditions, like diabetes or heart disease.

Naturally Slim is available at NO COST to you and is accessible via computer and mobile device so you can participate whenever it’s convenient, wherever you are.

For more information about Naturally Slim, visit ers.swhp.org

You don’t have to give up your favorite foods to lose weight and feel your best.

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ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (800) 321-7947 (TTY: 711).

Scott & White Care Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (800) 321-7947 (TTY: 711).

Scott & White Care Plans cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (800) 321-7947 (TTY: 711).

Scott & White Care Plans tuân thủ luật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa trên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hoặc giới tính.

Allowed Amount -This is the amount considered for payment based on our provider contracts and your benefits.

Amount Billed -This is the amount your provider billed for the services you requested. Note: this amount does not reflect discounts that the plan has negotiated with the provider or facility.

Amount Paid -This is the amount we paid to you or your provider.

Copay -This represents the amount you are responsible to pay for certain services, typically paid at the time of service.

Coinsurance - The coinsurance is a percentage of the “allowed amount” you are responsible for paying for services after your deductible is met. Providers may require payment when you receive services.

Deductible - A fixed-dollar amount the member is responsible for paying each plan year before the plan begins to pay for covered services. Note: “Non-Covered” amounts don’t count toward meeting the yearly deductible. Your provider may bill you for these charges.

Discount Amount -The amount you saved by using the plan’s preferred providers.

Non-Covered Amount - An amount you are responsible for paying because it is for a service that is not covered by your benefit plan. Also, if you’ve used an out-of-network provider, “non-covered amount” includes any amount the out-of-network provider bills in excess of the plan-negotiated network rates.

Other Coverage Payment -This is the amount paid by your other insurance carrier.

Out-of-Pocket Maximum -The most you have to pay for in-network health services every year. Once you have paid this amount, the Health Plan typically pays 100% of your allowed health care charges, subject to any policy limitations.

Helpful Definitions

If you suspect fraud, contact the Scott and White Health Plan Compliance HelpLine at (888) 484-6977.

Report Fraud

Language Assistance/ Nondiscrimination Notice

Get details on your claimswith your monthly insurance statement

Subscriber: John Smith

Member ID: 12345678

Group Name: Employees Retirement System

Group Number: 012700

Now...the Detailed VersionHere’s a detailed breakdown or Explanation of Benefits for this service. In case there’s any doubt - this is NOT a bill!

Notes:IJ THE PROVIDER IS NOT IN NETWORK AND/OR THERE IS NO AUTH ON FILE*If you elected to use your out-of-network benefit, the provider or facility may bill you for an amount greater than the amount reimbursed by the Health Plan. Out-of-network providers or facilities may not bill you for an amount greater than the copay/coinsurance/deductible indicated above in the following circumstances: emergency care services, treatment from an out-of-network provider while receiving services at an in-network facility, or for out-of network imaging or laboratory services if related to treatment from an in-network provider.

Patient: Ann SmithClaim Number: 123x456x788Provider: Test Provider 1

Out-of-Network*

Date of Service Description Amount

BilledAllowed Amount

Non-Covered Amount

Other Coverage Payment

Plan Paid Copay Deductible Coinsurance What You May Owe Notes

2/04/20 Emergency Dept Visit $1000.00 $500.00 $0.00 $0.00 $400.00 $100.00 $0.00 $0.00 $100.00 IJ

Total $1000.00 $500.00 $0.00 $0.00 $400.00 $100.00 $0.00 $0.00 $100.00

Patient: Ann SmithClaim Number: 123x456x789Provider: Test Provider 2

In-Network

Date of Service Description Amount

BilledAllowed Amount

Non-Covered Amount

Other Coverage Payment

Plan Paid Copay Deductible Coinsurance What You May Owe Notes

2/04/20 Office Visit $250.00 $150.00 $0.00 $0.00 $100.00 $50.00 $0.00 $0.00 $50.00

Total $250.00 $150.00 $0.00 $0.00 $100.00 $50.00 $0.00 $0.00 $50.00

QUESTIONS?

Customer service: (800) 321-7947Hours: 7 a.m. to 7 p.m. CT

Website: ers.swhp.org

Explanation of BenefitsThis is NOT a bill

1206 West Campus DriveTemple, TX 76502

Forwarding Service Requested

Member ID: 12345678Group Number: 012700Group Name: Employees Retirement SystemPrint date: 02/18/2020

John Smith789 TEST STREETREDCARD, MO 63141

Hi John,This document summarizes your recent benefit activity. It confirms the amount charged by your provider(s) and the amount we paid for those charges.

Cost breakdown

Amount billed: $1250.00

Plan discount: $600.00

Plan paid: $500.00

Not covered: $0.00

What you may owe

$150.00This is the portion of the billed amount you may

owe the provider(s) if payment was not collected at thetime of service. This amount may include

your deductible, copay, coinsurance, and/or non-covered amount.

Account Summary

Place holder for misc. communications

TotalAmount

AppliedAmount

Family Deductible

Family Out-of-pocket max$1,500.00

$2,477.84

$3,000.00($1,500.00 remaining)

$4,500.00($2,022.16 remaining)

Member Deductible

Member Out-of-pocket max

$250.00

$199.71

$1,500.00($1,250.00 remaining)

$2,250.00($2,050.29 remaining)

SWCP makes available through the Member Portal an electronic Monthly Insurance Statement, also known as an Explanation of Benefits (EOB), to help you manage your claims expenses at a detailed level. The statement provides line-item detail on charges for that month, including what was billed and covered by SWCP. The amount you owe is included in this statement.

Remaining balances for deductibles and out-of-pocket expenses are also reported. Information for the current month and year-to-date is included. Statements are not provided for prescription claims or claims where the member does not owe anything.

Your EOBs will be available on the Member Portal unless you specifically request to receive paper EOBs in the mail. To request paper EOBs, log in to the Member Portal and select “Update Preferences.”

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Even if your EOB isn’t yet finalized for a particular medical claim, you can still view your claim details in the Member Portal.

Don’t wait for your EOB View your claim on the Member Portal

Then click on any amount under “Plan Pays” to view the Claim Snapshot or Service Details. The Claim Snapshot provides key claim information, and Service Details itemizes the claim.

Click the SAVE icon to create a file that can be printed or saved.

EOBs are added to the portal monthly. Click on the Claim Number (in Claim No. column) to see your EOB.

Simply log in to the Member Portal through

ers.swhp.org and click on “Claims” from the menu

on the left side.

Claim Snapshot2

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1

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Complex Case Management If you have chronic conditions or complex care needs, our nurse case managers will work with you, your family, and your physician to create and manage your care plan. Case managers advocate for you and can help you navigate the healthcare system and arrange the services you need. They can also answer questions and help you understand your condition and care plan. If Disease Management is right for you, they’ll incorporate the program into your care. There is no additional cost to you for this voluntary program. It’s all part of our goal to help you get the best possible results and the greatest value from your health plan.

Disease ManagementDisease Management empowers you to manage your chronic condition and help prevent complications. We work with your healthcare providers to identify chronic conditions quickly and treat them effectively. We can also identify self-care activities that help you manage your condition at home. Together, we’ll work to slow down the progression of your disease and help you stay better, longer.

Stay better, longer

Accountable Care OrganizationAs a member of a health plan working with an Accountable Care Organization, you can expect care that is:

HIGH-QUALITY. You should expect the care you receive to be safe, timely, effective, efficient, equitable and patient-centered.

COORDINATED. Your doctor guides your care team and coordinates appropriate services across all sites of care that might include a specialist’s office, the hospital, or laboratory and imaging services.

CONVENIENT. Many of our doctors and facilities offer same-day appointments, extended hours, and onsite laboratory and imaging services. Urgent care centers and retail care clinics like Walgreen’s and CVS are in the BSW Preferred network.

COMPREHENSIVE. The BSW Preferred network of primary and specialty care doctors and facilities is broad. We are confident we can meet your care needs.

COST-EFFECTIVE. Copays and out-of-pocket expenses are kept in check when your care needs are delivered inside the BSW Preferred network (doctors, hospitals, laboratory, imaging and post-acute care.) All other providers are considered out-of-network and no benefits are available for services other than emergency situations.

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Tools and resourcesOur most frequently requested documents and forms are available within our Tools and Resources section. At ers.swhp.org, select the Menu (top left corner by the logo), then select Tools and Resources to locate information about:

• Member Rights and Responsibilities

• Notice of Privacy Practices and Authorization to Release PHI Form

• Prior Authorization List for Medical Procedures

• Complex Case Management Program with Multiple Referral Options

• Disease Management Program

• Utilization Management (UM) Program- How to Access UM Staff- TDD/TTY Services for Members- Language Assistance for Members- Utilization Management Affirmative Statement

• Quality Improvement Program and Progress in Achieving Goals

• Medical and Pharmacy Claim Forms

• Pharmaceutical Management Procedures and Updates

• Wellness Assessment and Programs

• Glossary of Key Terms

• Technology Assessment Program

• Language Assistance

• Member Frequently Asked Questions (FAQ):- Submit a Claim- Obtain Information About Participating Providers - Obtain Primary, Specialty, and Behavioral Healthcare- Obtain Hospital Services- Get Care After Normal Office Hours- Get Care Outside the SWCP Service Area- When to Call 911 - File Complaints and/or Appeals

Printed copies of documents and language assistance are available by calling

(800) 321-7947.

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HMO products are offered through Scott and White Health Plan and Scott & White Care Plans. Insured PPO and EPO products are offered through Insurance Company of Scott and White. All are Texas registered insurance companies. Scott & White Care Plans and Insurance Company of Scott and White are wholly owned subsidiaries of Scott and White Health Plan.

Thank you for choosing Scott & White Care Plans for your healthcare coverage needs.